also a manhole over the sewer just in front of the house. Inthe third house there had been two cases of typhoid fever andtwo cases of scarlet fever. At the back there was anothersewer ventilating pipe, but what was particularly significantis the fact that this pipe had been broken off at the top.Instead of being carried upon and above the roof of thehouse the pipe abutted immediately under the ledge of theroof. The air coming out of this pipe would therefore strikethe ledge of the roof and would be deflected downwards.Following the wall the sewer air would reach the upperportion of the two windows of the two bedrooms situatedon each side of the pipe. The mouth of the pipe was notmore than two feet or so from these windows and it wasprecisely those persons who slept in the two rooms thusexposed to the invasion of sewer air who fell ill with typhoidfever and with scarlet fever.
In the Monks-road I found another equally significantcombination of circumstances. Here in a very pleasantlooking villa close to the park and well situated on the wideroad there have been two cases. The first was that of ayoung lady whose bedroom window overlooked the roadmanhole. Such bad odours escaped from this manhole thatthe inhabitants of the house often poured down bucketfuls ofdisinfectants in the hope of reducing the nuisance. The
lady’s brother was the second to fall ill from typhoid fever.His bedroom window was round the corner of the villa over-looking the side street. Immediately by his window a sewerventilating pipe goes up to the roof of the house. Noodour, I was told, had been noticed coming downfrom the roof but there is a joint in the pipe aboutfive feet above the ground. There was no lead or cement inthis joint and the two pieces of the cast-iron ventilating pipefitted so badly that the sewer air came out freely. The odourcould easily be detected. It blew into the side door whichwas close by and thence into the pantry where the foodis kept, or else it ascended up to the window of the roomimmediately above. It was in this room that the brotherwho contracted the fever was in the habit of sleeping.Several other houses where there had been cases of typhoidfever were also especially subject to receive air escapingfrom the sewer but of course there has not been time yet togo into this matter thoroughly. Still, and though these inci-dental cases must not be taken as conclusive, they dosuggest a possible connexion between the escape of sewer airand the greater prevalence of fever in certain districts,streets, and houses. If that can be more conclusively demon-strated than is possible in this preliminary examination oflocal conditions then we have yet another proof that theventilation of sewers is, generally speaking, a question thathas not been satisfactorily solved. At Lincoln as muchattention has been devoted to this matter as in most othertowns and yet the present state of affairs seems fraughtwith no inconsiderable danger.
TUBERCULOSIS IN FRANCE.
(FROM A SPECIAL CORRESPONDENT.)
L’Œuvre des Enfants Tuberculeux.IN view of the International Congress against Tuber-
culosis to be held in Paris next October English readersmay be interested to become acquainted in advance with
L’Œuvre des Enfants Tuberculeux. This popular society,having for its object the free treatment under idealcondi-tions of tuberculous children, was founded under its modesttitle in 1888, when a country residence at Ormesson, 26 kilo-metres outside Paris, was given for the purpose and wasopened to receive 12 patients. In 1894 it received the well-recognised distinction of being officially declared to be ofpublic utility. The moving spirit of the movement has beenDr. Leon-Petit, its secretary-general; but its list of sup-porters, members of committee, and past presidents includeDr. Brouardel, senior French representative at the LondonCongress; Dr. Herard, President-elect of the comingCongress in Paris ; Dr. Hutinel, professor of pathology ; Dr.Blache, its late president, and Dr. Graucher from the medicalprofession; M. Jules Simon, M. Georges Picot, M. CasimirPerier, and M. Emile Loubet from the world of literature andpolitics, and a considerable number of well-known namesbelonging to the old French aristocracy. At the annual
meeting held on Feb. 9th the Agricultural Hall of Paris
was packed full of the society’s supporters, most by appear-ance of the bourgeoisie, who stood for hours in the doorwaysand stairways listening to the speeches, which lasted twohours, before they could be rewarded with a first-rate pro-gramme of music and recitation provided by popular actressesand platform musicians. To English minds, accustomed toMansion House meetings and charitable funds on a vast scale,a national work spending under £8000 in the year on 400tuberculous children would hardly seem likely to present anyvery thrilling interest. But organised philanthropy is stillin its infancy in France and in philanthropy, as in every-thing else, the Frenchman makes the most of whathe is spending and the meeting was an enthusiastic success.The visit to the hospitals here described was kindly arrangedin special honour of the visitor who was received a coupleof days later at the station of Villiers-sur-Marne by Dr.Vaquier, the physician in charge, who is also allowed toengage in private practice. Villiers is 21 kilometres out ofParis from the Gare de 1’Est, and standing high it commandsa fine distant view of the city, embedded away to the westtowards late afternoon in the golden haze of a wintry sunset,The three hospitals of this society all lie within a few milesof each other to the E.S.E. of Paris. The most recent, thatat Noisy-le-Grand, which is passed in the train, was openedonly two years ago for girls of from three to 10 years ofage. The first at Ormesson has about 100 beds for smallboys from three to ten, while that at Villiers has nearer200 for boys from 10 to 16 years of age. All alike are
managed by religious sisters of Sainte-Anne, women devotedto the work although devoid of any previous systematicprofessional training, but the older boys at Villiers are
managed as regards discipline and education by men ofsimilar standing to board school masters.The small boys’ hospital, or sanatorium as we should call
it, at Ormesson is centred round a country house given forthe purpose in 1888. This is now used by the seven or
eight sisters who control the whole management and do mostof the menial work themselves. On one side there has beenadded a fine, lofty, and spacious dining hall, with kitchens atthe end and long windows down either side. A hundredlittle boys were standing in blue smocks beside two longtables and as the sister gave the command by a woodenclapper they recited a grace, crossed themselves, and satdown to their afternoon milk. Children of any creed or
race are received without distinction ; but as there is a
bright little Roman Catholic chapel and the discipline is inthe hands of réligieuses it is probable that all have to con-form for the time to Roman Catholic practice. The dininghall looked bright, clean, and airy but there is a greatobjection to the French windows, which open down theirwhole length or not at all, insomuch that during most ofthe year the children sit with closed windows. Hot airis certainly admitted freely but its freshness is always opento suspicion, even if it does drive out the stale air throughthe outlets designed for the purpose in the roof. This
appears to be a radical defect in house construction through-out France and above all in houses intended for the treat-ment of pulmonary tuberculosis. From the central buildingare also built out at either side two long, spaciousdormitories, floored in wooden parquet and equipped withnothing but simply furnished beds - and a few chairs; whileat the end are the lavatories, baths, and water-closets withoutwooden seats ; small sleeping rooms for the sisters in charge;a room at each end for isolation of infectious cases, forinstance, of measles or scarlet fever, which have hithertobeen here successfully isolated ; and along the southern faceof each dormitory runs an open, flagged verandah. Finally,this southern face is completed by a fine, lofty hall, builtup against the original house ; floored in linoleum, with tiledand painted walls and rounded corners, equipped with lowbenches and a few long chairs for invalids, and used asa playroom in all weathers. The grounds to an Englisheye are dull and uninteresting, with long stretches of roughgravel and no signs of swings or games. At the entranceis a pavilion in which relatives and friends are received andwhere they can see the children.The big boys’ hospital at Villiers is now a considerably
larger affair. Based on a house belonging to M. Bonjeanwho took in ten waifs in 1891, it was enlarged by a coupleof wings to take in 40 tuberculous children in 1892. In 18935000 from the Pari-Mutuel enabled the society to Luild ahospital ward and gallery and by an extensive popular sub-scription, entitled " Les Enfants de France," a new pavilionof large dimensions was inaugurated by M. Faure in 1896
and dedicated to the memory of Villencia, the military t
surgeon who described the contagious nature of phthisis and who is celebrated by a bust in the courtyard of Val-de-Grâce as also by a good statue in the hall at Villiers. The names ofthe chief donors amongst the 12,000 subscribers are set out in detail on the wall of the staircase. Finally, there have 1
just been completed the workshops for making clothes and 1
boots and the long covered playroom on one flank of thebuilding and on the other the workrooms, laundry, andmachine-house in which a gas engine runs a dynamoand pumps water for the establishment. Owing to the
workshops the staff of sisters here numbers 25.The Pavillon des Enfants de France is certainly of a
remarkably original and interesting design. It is built intwo floors-ground floor and gallery-round a large, open,central space. The gallery is of light iron and wood con-struction and the whole impression is like that of a museum,the place of the cases being taken by very frigid-lookingbeds or in the central, slightly sunken well by a few stiffchairs and tables. The building measures some 120feet by 70 feet and is nearly 60 feet high, with a
half-glazed roof and English sash windows all the wayround on both floors. The beds were ranged mathe-
matically round the gallery and round the outer regionunder the gallery on the ground floor. At the corners
were windowed cubicles for the surveillants. On both floorswere doors opening into lavatories, bathrooms (three bathsto each floor), and dressing rooms. This pavilion is used asa sleeping room only at night. Patients confined to bedare retained in the older dormitory, which is more like anordinary hospital ward, with a closed gallery along one side,where they can be quieter and can be attended to by one ofthe sisters. Round the house is a good garden on whichsome care has been expended to asphalt the paths and tokeep down the dust in summer. It is difficult to say, at leastwithout spending some time as an inmate, if any advantageis gained by a large, open pavilion such as this at Villiers.Given English windows and the recognised English demandfor fresh air, it is probable that tuberculosis may be as welltreated in a bedroom or ordinary ward as in any of specialsize or design. The French public, however, even more thanthe English, have a rooted aversion to cold air, preferringhot and stale at all costs. If the windows, then,are of French design or if, being on the sash principle,they are kept closed throughout the night, there is some realexcuse for the eccentric design of the Pavillon des Infantsde France. As to artistic merits, the worker in Englishhospitals is completely spoiled for any appreciation ofFrench wards. The religious sister, the surveillant, theinfirmier, all alike seem to work by hard and unbending ruleof thumb. The discipline appeared rigid; there were no signsof spontaneous gaiety amongst the children who appearedto be essentially at school ; in no ward apparently wasthere a piano, or picture, or note of decoration, and therewere no cushions or ribbons, no flowers, and no toys. Ifthe womanly touches, familiar to our English wards, despitethe alleged professionalism of our nurses, be thus absent,surely there must be a corresponding lack of that sympathywhich at all ages is a strong power for good and in child.hood is one of the most important factors in any treatment.The general stay of a child in hospital is from two to six
months. Many stay for longer, some for years; but it isbest to send them back if possible within half a year, forafter that length of absence the parents become unwilling to
take tjiJCiil liumc OfU all. The ULLiliUdB Ult5CbLUU WC-JLC, Hi
for instance, at Ormesson 167, Villiers 149, and Noisy-le-for instance, at Ormesson 167, Villiers 149, and Noisy-le-Grand 79, total 395. Their average stay in hospital was 71days; and the general result of several years past has been amortality of 10 per cent. and an apparent recovery rate offrom 25 to 27 per cent. Cases are admitted by recommenda-tion of the family medical adviser, declaring the existenceof pulmonary tuberculosis, corroborated by examination atthe hands of a medical admission-committee and by a domi-ciliary visit paid by female inspectors. The year’s expensesinclude R800 invested; R2000 for central stores, drugs, andshops; £1300 for dispensary and offices in Paris ; R900 forOrmesson; k2000 for Villiers ; £1100 for Noisy ; and £250for a now extinct sanitary colony at Trenilly ; total, £8600.The upkeep of a bed is quoted at E20 a year. Any sub-scriptions from 8s. a year upwards qualify for membershipof the society of varying grade.
Ze Dispensaire dntitacberczclezcx Emile Roux de Lille.An English visitor to Paris may well stop on his way
Lhrough Lille and see M. Calmette’s antituberculous dis-
pensary as a type of work which has a future before it ofthe very first importance. There is a Fédération des ŒuvresAntituberculeuses Franchises, the monthly organ of which,entitled La Lutte Antituberculeuse, gives from time totime most excellent accounts of the theory and prac-tice of these dispensaries, but a few brief notes may notbe out of place in the pages of THE LANCET, to followthe account given of sanatoriums on the ordinary planat Bligny, Ormesson, and de Villiers. The principle may bebriefly stated. Tubercle kills 150,000 Frenchmen everyyear, a population equal to that of Rouen or Nantes ;the friendly societies spend .6160,000 a year on 75,000cases of tubercle; ;E8,000,000 would be required to buildand £3,000,000 yearly to maintain the anatoriums re-
quired for their treatment. And the treatment is long,doubtful, and unacceptable to most working people. Withoutin any way underestimating the value of sanatorium treatmentas the ideal, especially for curable cases, the presont move-ment has as its object to initiate dispensaries in the towns asthe indispensable adjunct of the sanatoriums. Its essentialaim is not that of charity, to supply medical advice and todistribute drugs or doles, but rather that of national economy,to save to the State as many working lives and working daysas possible. The dispensary is the ideal antituberculousschool for adults. It seeks, therefore, to find out all casesof poor consumptives, to attract them and to keep control ofthem, to understand their local conditions, to advise themeither to apply for sanatorium or other hospital treatment forthemselves or at least to take steps to prevent the spread ofinfection; and for these ends to give them material assist-ance in the unequal struggle with disease in which they findthemselves placed through no fault of their own. Lille ischosen as a sample of a great industrial city in which,out of a population of 220,000 persons, there are 6000 poorconsumptives, of whom from 1000 to 12C0 die every year.The precise method employed at the dispensary is as
follows. A new case is received from 4 to 6 on any week-dayevening and from 9 to 11 any Sunday morning, and is givena card for consultation on a particular day at a particulartime, so as to avoid his being kept waiting, together witha pocket spittoon in which he is to bring a specimen ofhis sputum. At the appointed time he is seen by themedical director or one of his three assistants, who makes athorough physical examination and verbal investigation ofthe case and registers the details on his clinical history sheet(dossier) with a minute account of his family history, habits,and surroundings. If there is no suspicion of tubercle thepatient is discharged. If, however, tubercle is diagnosed orsuspected he is given a carefully worded pamphlet (which isfully explained to him) of instructions as to the precautionsto be taken and his own interest in the matter ; he is sup-plied with pocket and table spittoons and a litre of lysol andis told when to come for a second visit. The next steptaken by the dispensary is the personal inquiry by a workingman. It is recognised that none but a working man can fullybe received as his equal by a working man or can be expectedto find out the exact conditions of his life or to enter fullyinto his difficulties in suggesting plans for its amendment.A working man, M. Haenjens, has therefore been engagedby the dispensary, himself formerly a woolcomber and secre-tary of a benefit society, who speaks both Flemish andFrench and has been thoroughly trained in the principles ofdomestic sanitation and the fight against tubercle. He now
pays a visit to the home of the patient and is usually able,with a hearty welcome, to confirm, to enlarge, or to modify thereport already given as to his hygienic, financial, and generalsurroundings, both at home and in his workshop. On thisdouble report, the dossier clinique and dossier ouvrier, thedirector of the dispensary decides as to the measures to beadopted. From 50 to 60 families have their soiled linen disin-fected and washed in the special laundry of the dispensary everyweek. The patient’s room, if assent is obtained, is thoroughlydisinfected, stripped of its paper, and washed from time totime ; if necessary, he is provided with a weekly paymentfor a fresh lodging. Through the dispensary he may be fur-nished by the charitable with bed and clothing and some 120are in receipt of daily outdoor relief in the shape of orderson local provi(lers for-to take instances at random from theorder-book-30 litres of milk for the month, a month’slodging, or supplies of eggs, meat, or coal. Some are givenwarm douches every day ; some are relieved of the care oftheir children, who are billeted out on other families or sentto the sea sanatorium at Luydcoote, near Dunkerque. This
year it is hoped to send a few select and curable cases withtheir families to small, healthy houses, especially built forthe purpose, out in the wcorUand and the country air.The Emile Roux dispensary at Lille was founded in 1901
as the result of a public subscription, doubled by a vote ofthe municipality, which also provided an admirable site inthe Boulevard Louis XIV., where it is now almost hiddenbetween the imposing Pasteur Institute on the one side andthe city walls on the other. It is essentially, as desired, inthe poor and industrial quarter of the town. It is simplybuilt-a one-floored building measuring 42 by 35 feet besidesannexe-with ample accommodation for a large out-patientattendance, every attention being paid to the requirementsof light, air, and cleanliness. Out of a good-sized waitinghall there opens on one side the office of the workman-inspector ; on another side are a couple of medical consultingrooms with a dark room and a clinical laboratory for exa-mination of sputa ; on the third side are an office where allregisters are kept and a passage leading to a glass-roofedhall where patients are accustomed to the use of a longchair and are taught breathing exercises. Beyond this is anannexe, including the douches, laundry, and drying rooms,and a room for the receipt, sterilisation, and distribution ofmilk. The total cost of building and equipment was £1440.The information thus being collected is of considerable
importance and interest. Of 592 patients examined in a year261 were suspected of tubercle, 144 male and 117 female, 81and 86 respectively being between the ages of 20 and 40years. In the first three years during which the dispensarywas open, 1901-03, 780 cases were diagnosed as tuberculous ;most occurred in the months from February to Julyand least (5 per cent.) in the month of January. Thefirst six decades of life contributed respectively 9, 129.271, 238, 105, and 26 cases, five only being diagnosedin persons over 60 years of age. The majoritybelong to the textile or clothing industries ; andcome from the most crowded and least airy quarters of thecity. Physical overwork, according to a recognised criterion,was found in 98’22 per cent., insufficient feeding in 71’26per cent., alcoholism in 15 32 per cent., defective sanitationof workshops in 16’09 per cent., tuberculous parentage in20’68 per cent., other tuberculous relationship in 19’ 54 percent., and contagion only in 9’ 19 per cent., being two casesin public life and 22 in marriage. Most live in smallrooms, in overcrowded rooms, or in rooms with only onewindow or skylight. Of the 152 invalids receiving materialassistance on an average for six months in 1903, 51 increasedin weight an average of eight pounds, 38 remained stationary,and 63 diminished an average of five and half pounds. Formedical results, 17’76 per cent. are returned as improved,25’65 as stationary, 19’ 73 as aggravated, and 36’ 84 asdead.The cost of the establishment is comparatively slight. The
medical service, including the director, costs z126 ; inquiriesand sanitation of rooms, £84 ; cleaning and administration,£90 ; laundry, £64 ; spittoons..613 ; with other general ex-penses amounting to a total of £550. The material assistanceto 347 families in 1903 amounted to £966, including E360 formilk, E284 for eggs, Z160 for meat, £80 each for coal andlodging, and E18 for sencling children to the sanatorium. Thetotal cost of the dispensary, therefore, for the year was37,850 francs, or f:1514, or roughly £10 for each invalid andhis surroundings. It may be objected at first that thematerial assistance is in danger of pauperising the invalids,and this will undoubtedly be the case if proper care is nottaken. But the essential object of this material help is toattract and to keep in touch with the adult pupils of this anti-tuberculous school, and, consistent with the attainment ofthis object, it rests with the director and, above all, withthe workman-inspector to see that the funds are used to
good advantage. The essence of the system, in fact, isthe workman-inspector, and considering how easy it is in
England to find men of this class coming forward to pass theexaminations of the Royal Sanitary Institute and to competefor the position of sanitary inspector there should be everyhope of the system being adopted with good effect in someoE our large English cities. Dr. A. Newsholme and othershave decided that the great work of a sanatorium fortuberculosis is to train its inmates for their future life athome. This training needs to be confirmed, continued,supervised, extended, or supplemented by some such insti-tution as the antituberculous dispensaries of France andBelgium, of which a most notable example is afforded bythat under the guidance of Dr. Calmette at Lille.
(FROM OUR OWN CORRESPONDENT.)
University Intelligence.Mr. Jordan Lloyd, professor of operative surgery, has
been elected to represent the Faculty of Medicine upon theCouncil of the University, vice Professor H. G. Barling whoas Dean of the Faculty is ex officio a member of the Council,-The Huxley lecture this year will be delivered on Thursday,March 23rd, by Professor E. B. Poulton, M.A., F.R.S., of theUniversity of Oxford. ,
’ Mentally and Physically Irefeeti-ue Children.The school accommodation for mentally and physically
defective children was considered at the last meeting of theBirmingham education committee. Mrs. Hume Pinsent pre-sented the report of the special schools subcommittee, fromwhich I gather that there are about 1000 mentally defectivechildren in the city, less than half of whom are receivinginstruction in special classes. Excluding feeble-mindedcripples, who are not eligible for any school in Birmingham,it is estimated that school accommodation should be pro-vided for 600 feeble-minded children, whereas at presentthere is only accommodation for a little over 300. Thescheme submitted by the subcommittee further included theprovision of a boarding school in order to organise and tocomplete the work done for defectives. It was pointed outthat the industrial homes for the feeble-minded whichare about to be erected by the Poor-law guardians willbe incomplete without some such boarding school. Itwas stated that the effect of adopting the scheme wouldbe that an adequate education would be given to 1000 feeble-minded children at an annual cost of .610,000 insteadof, at present, an inadequate education to 500 at an annualcost of £3400. In the discussion which followed most of thespeakers were in favour of the scheme and the report wasfinally approved, with the exception, however, of that partrelating to the boarding, school.
Increase of Lunancy.Councillor Davis, the chairman of the lunatic asylums
committee of the city council, in a recent address gave somestatistics which although they were selected arbitrarily maybe taken as showing that there has been a 100 per cent.increase of patients suffering from lunacy during the last 40years in Birmingham. He expressed the opinion that drinkwas accountable for a greater proportion of the cases of
insanity in Birmingham than in England as a whole and thatdrink and hereditary influence were respectively accountablein Birmingham during the quinquennial period of 1898-1902for 17’ 9 per cent. and 26’ 8 per cent. of the admissions. Heconsidered that in view of the large proportion of cases dueto the latter cause something should be done to preventinsane patients having children.
The Unemployed.The conference to which I referred in my last letter
as shortly to be held between representatives of the citycouncil and the three local boards of guardians was wellattended. The feeling of the meeting was favourable tothe acceptance of Mr. Fels’s offer to lend land for theformation of a labour colony and a subcommittee was
appointed to consider the details of the scheme. One ofthe difficulties in the way, according to one of the speakers,was that if land could not be obtained in the neighbourhoodof Birmingham the authorities would either have to sendout the men by railway or to provide barracks for them.Professor Muirhead of the University contributed some notesupon the conference to the press. He thought that thecontinental labour colonies had been a failure and thatbefore embarking on such expensive schemes we should givea more prolonged trial to labour registries, that childrenshould be more frequently brought up with a knowledge ofsome trade, and that membership of the various workmen’ssocieties should be more universal. He expressed himself asnot altogether in favour of work relief in preference to reliefin food or money, since those engaged in such work wereoften unsuited and during the time they were at work theywere prevented from seeking employment in their own
trades.Housing in Birmingham.
Some years ago certain land at Bordesley Green wasacquired under the Housing of the Working Classes Act